Renal functional outcomes after robotic multiplex partial nephrectomy: the National Cancer Institute experience with robotic partial nephrectomy for 3 or more tumors in a single kidney

A Systematic Review of Surgical Outcomes: Comparing Robotic-Assisted Partial Nephrectomy and Open Partial Nephrectomy in Nephron-Sparing Surgery for Renal Tumors

A partial nephrectomy is a critical approach for nephron-sparing surgery in renal tumors, striking a balance between oncological control and the preservation of renal function. Surgeons traditionally view open partial nephrectomy (OPN) as the gold standard in kidney surgery. The emergence of robotic-assisted partial nephrectomy (RAPN) offers a minimally invasive alternative that can improve surgical precision and decrease the risk of complications during the perioperative period. This systematic review analyzes and compares OPN and RAPN based on factors such as oncological effectiveness, preservation of kidney function, perioperative outcomes, and complication rates. We followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to review and include studies, analyzing 30 studies that involved more than 26,826 patients. The research team carried out retrospective and prospective cohort studies and randomized controlled trials (RCTs). They measured the quality of these studies by using the Newcastle-Ottawa Scale (NOS) for observational studies and the Cochrane Risk of Bias tool version 2 (RoB 2; Cochrane, London, UK) for RCTs. Our findings indicate that RAPN offers significant perioperative advantages, such as reduced mean estimated blood loss (EBL) of 181 mL compared to 284 mL for OPN and shorter hospital stays averaging three days compared to six days for OPN. Follow-up durations ranged from three to 60 months. Although the surgery for RAPN takes longer, it consistently preserves renal function better, resulting in less considerable declines in the estimated glomerular filtration rate (eGFR). Oncological outcomes show that RAPN achieves a negative surgical margin (NSM) rate of 97.16%, while OPN reaches 92%. RAPN effectively handles complex renal tumors, especially those with high Preoperative Aspects and Dimensions Used for Anatomical (PADUA) or R.E.N.A.L. Nephrometry score (Radius (R), Exophytic/Endophytic properties (E), Nearness to the collecting system or sinus (N), Anterior/Posterior location (A), Location relative to polar lines (L)). In conclusion, RAPN offers significant advantages in perioperative and functional outcomes while maintaining oncological equivalence to OPN. This seals RAPN as the preferred approach in centers with robotic expertise. However, OPN remains a viable option in low-resource settings. Future research should improve access to robotic systems, standardize reporting metrics, and conduct long-term randomized trials to understand both techniques' strengths and limitations better.

Renal cell cancer treatment: the Latin American Cooperative Oncology Group (LACOG) and the Latin American Renal Cancer Group (LARCG) surgery-focused consensus update

Renal cell carcinoma (RCC) represents 2.2% of all malignancies worldwide; however, its mortality rate is not negligible. Surgery is the primary treatment for most nonadvanced cases, with its indications and techniques evolving over the years. To provide an update on RCC management in Brazil, focusing on surgery. The Latin American Cooperative Oncology Group-Genitourinary Section and the Latin American Renal Cancer Group gathered a panel of Brazilian urologists and clinical oncologists to vote on and discuss the best management of surgically resectable RCC. The experts compared the results with the literature and graded them according to the level of evidence. For small renal masses (SRMs; less than 4 cm), biopsy is indicated for specific/select cases, and when intervention is needed, partial nephrectomy should be prioritized. Radical nephrectomy and ablative techniques are exceptions for managing SRMs. Patients with small tumors (less than 3 cm), slow tumor growth, or a risk for surgery may benefit from active surveillance. Localized carcinoma up to 7 cm in diameter should be treated preferably with partial nephrectomy. Lymphadenectomy and adrenalectomy should be performed in locally advanced cases if involvement is suspected by imaging exams. Patients with venous tumor thrombi usually require surgical intervention depending on the extent of the thrombus. Neoadjuvant therapy should be considered for unresectable cases. Even in the era of targeted therapy, cytoreductive nephrectomy still has a role in metastatic disease. Metastasectomy is indicated for most patients with resectable disease. This consensus presents recommendations for surgical treatment of RCC based on expert opinions and evidence from the medical literature. Surgery remains the best curative option for nonadvanced cases, and it still has a role for select patients with metastatic disease.

Cumulative Impact of Serial Partial Nephrectomy for the Treatment of Recurrent Renal Masses

PURPOSE

Reoperative partial nephrectomy (RePN) offers several advantages for the treatment of recurrent, multifocal renal masses. RePN has been previously demonstrated to be technically feasible and delay the need for renal replacement therapy. However, there is still inherent complexity and known risks to reoperative nephrectomy. We studied the largest population of RePNs to characterize renal functional outcomes and the likelihood of intra- and postoperative complications.

MATERIALS AND METHODS

Query of an institutional surgical registry was conducted. Demographic data, serum creatinine for estimated glomerular filtration rate (eGFR), and protein dipstick results were assessed within 1 week prior to surgery, and postoperative function assessments were studied within a year of surgery. RePN was defined as serial surgical resection of the ipsilateral renal unit.

RESULTS

A total of 1131 partial nephrectomies performed on 663 patients at a single center were retrospectively evaluated. In reoperative cases, median number of operations per renal unit was 2 (range: 2-6). There was a stepwise decline in eGFR with an average decline of 6.1 with each RePN. With each subsequent nephrectomy, surgical duration, estimated blood loss, and incidence of preoperative anemia increased. Postoperative eGFR showed a significant positive association with preoperative eGFR, while negative associations were found with age, number of previous ipsilateral partial nephrectomies, number of tumors, and largest tumor size. High-grade complications were associated with the number of ipsilateral partial nephrectomies, tumor count, and tumor size. Robotic or laparoscopic procedures exhibited a likelihood of grade 3 or greater complications compared to open surgery.

CONCLUSIONS

RePN contributes to renal dysfunction and an increased risk of surgical complications. Intraoperative blood loss and surgical duration increase with subsequent nephrectomy. Such risks are dependent on the number of prior operative interventions on the kidney, suggesting a stepwise progression of surgical morbidity.

A systematic review of robot-assisted partial nephrectomy outcomes for advanced indications: Large tumors (cT2-T3), solitary kidney, completely endophytic, hilar, recurrent, and multiple renal tumors

Objective

Robot-assisted partial nephrectomy (RAPN) has become widely used for treatment of renal cell carcinoma and it is expanding in the field of complex renal masses. The aim of this systematic review was to analyze outcomes of RAPN for completely endophytic renal masses, large tumors (cT2-T3), renal cell carcinoma in solitary kidney, recurrent tumors, completely endophytic and hilar masses, and simultaneous and multiple tumors.

Methods

A comprehensive search in the PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials databases was performed in December 2022 for English language papers. The primary endpoint was to evaluate the role of RAPN in the setting of each category of complex renal masses considered. The secondary endpoint was to evaluate the surgical and functional outcomes.

Results

After screening 1250 records, 43 full-text manuscripts were selected, comprising over 8500 patients. Twelve and thirteen studies reported data for endophytic and hilar renal masses, respectively. Five and three studies reported outcomes for cT2-T3 and solitary kidney patients, respectively. Four studies focused on redo-RAPN for recurrent tumors. Two studies investigated simultaneous bilateral renal masses and five reports focused on multiple tumor excision in ipsilateral kidney.

Conclusion

Over the past decade, evidence supporting the use of RAPN for the most challenging nephron-sparing surgery indications has continuously grown. Although limitations remain including study design and lack of detailed long-term functional and oncological outcomes, the adoption of RAPN for the included advanced indications is associated with favorable surgical outcomes with good preservation of renal function without compromising the oncological result. Certainly, a higher likelihood of complication might be expected when facing extremely challenging cases. However, none of these indications should be considered per se an exclusion criterion for performing RAPN. Ultimately, a risk-adapted approach should be employed.

Robotic-Assisted Partial Nephrectomy: Techniques to Improve Clinical Outcomes

PURPOSE OF REVIEW

To summarize current options available for robot-assisted partial nephrectomy RECENT FINDINGS: Partial nephrectomy (PN) is a standard treatment option for management of cT1 renal masses. It may be carried out by multiple approaches. Robot-assisted (RA) PN is one such option. The goal of treatment is both correct oncological (negative surgical margins) and functional (preservation of sufficient amount of renal parenchyma of the operated kidney) outcome. Appropriate outcomes depend on multiple factors. There are many, but among others tumor characteristics (size, location, i.e., tumor complexity), patient baseline renal function, patient comorbidities, and performance status etc. Based on all these, the surgeon adapts the intervention for each mass/patient by preoperative planning, absence/use/duration of warm or cold ischemia, perioperative imaging, resection technique adapted to tumor location and depth of invasion, use of hemostatics, type and degree of renal parenchymal closure and others details. Nephroprotective agents have not shown efficacy so far. It should not be forgotten that surgeon's experience plays a key role in the achievement of good results. Although multiple factors have a role in the RA partial nephrectomy, surgeon experience and adaptation of technique of intervention have the crucial role in the achievement of both functional and oncological results.

Growth Rates of Genetically Defined Renal Tumors: Implications for Active Surveillance and Intervention

PURPOSE

Published series of growth rates of renal tumors on active surveillance largely consist of tumors without pathologic or genetic data. Growth kinetics of genetically defined renal tumors are not well known. Here, we evaluate the growth of genetically defined renal tumors and their association with patient clinical and genetic characteristics.

PATIENTS AND METHODS

We evaluated patients with an inherited kidney cancer susceptibility syndrome as a result of a pathologic germline alteration of VHL, MET, FLCN, or BAP1 with at least 1 solid renal mass managed with active surveillance at our institution. Tumor growth rates (GR) were calculated and patients were stratified by genetic alteration and other clinical and genetic factors to analyze differences in growth rates using linear regression and comparative statistics.

RESULTS

A total of 292 patients with 435 genetically defined tumors were identified, including 286 VHL-deficient, 91 FLCN-deficient, 52 MET-activated, and 6 BAP1-deficient tumors. There were significant differences in GRs when stratified by genetic alteration. BAP1-deficient tumors had the fastest median GR (0.6 cm/y; interquartile range [IQR], 0.57-0.68 cm/y), followed by VHL-deficient tumors (GR, 0.37 cm/y; IQR, 0.25-0.57 cm/y), FLCN-deficient tumors (GR, 0.10 cm/y; IQR, 0.04-0.24 cm/y), and tumors with MET activation (GR, 0.15 cm/y; IQR, 0.053-0.32 cm/y; P < .001). Tumors from the same patient had similar GRs. Younger age was independently associated with higher GR (P = .005).

CONCLUSION

In a cohort of genetically defined tumors, tumor growth rates varied in a clinically and statistically different manner according to genetic subtype. Rapid growth of BAP1-deficient tumors indicates that these patients should be managed with caution. The faster growth of tumors in younger patients may support more frequent imaging, whereas the slower growth of other tumors may support extended surveillance beyond annual imaging in some instances.

A comparison of outcomes for standard and multiplex partial nephrectomy in a solitary kidney: The National Cancer Institute experience

OBJECTIVES

To study the short and intermediate surgical, renal functional, and oncologic outcomes of multiplex partial nephrectomy (mPN) and standard partial nephrectomy (sPN) in the setting of a solitary kidney.

PATIENTS AND METHODS

Review of a prospectively maintained database of patients undergoing solitary kidney partial nephrectomy at our institution was performed. Patients were stratified into 2 cohorts: mPN-where 3 or more renal tumors were resected and sPN-where 1 or 2 tumors were resected. Perioperative, renal functional, and oncological outcomes were compared.

RESULTS

Ninety-three patients with a solitary kidney underwent a total of 121 surgical procedures; 43 (35.5%) were sPN and 78 (64.4%) were mPN. The total and major (Clavien Grade III and IV) complication rates between sPN and mPN were similar (57.1% vs. 70.1%, P = 0.2; 31.0% vs. 35.1%, P = 0.3). At 12 months post-op, the percentage of patients with eGFR > 45 was similar in each group (sPN 87.0%, mPN 73.7%; P = 0.2), and long-term hemodialysis rates were 4.7% and 6.4%, respectively. Completion nephrectomy was performed in 2.3% of sPN and 2.6% of mPN. At a median follow-up of 40.1 months, the metastasis rate was 8.6% in the sPN group and 4.1% in the mPN group (P = 0.4).

CONCLUSIONS

Partial nephrectomy in the setting of a solitary kidney can effectively preserve renal function. The renal functional and oncologic outcomes were similar in sPN and mPN, with low hemodialysis rates and complication rates within the expected range of these operations. Three or more tumors in a solitary kidney should not be a contraindication for nephron sparing surgery.

Organ-sparing procedures in GU cancer: part 1-organ-sparing procedures in renal and adrenal tumors: a systematic review

PURPOSE

Organ-sparing surgery (OSS) for the kidney and adrenals has emerged as the need for preservation of function is paramount in patients with poor functional reserve. As reports increasingly showed that oncological outcomes were equivalent to radical excision, elective OSS became a viable alternative in patients with otherwise normal reserve. In this review, we summarize the current knowledge of OSS for adrenal and renal tumors.

MATERIALS AND METHODS

PubMed, Web of Science and Cochrane Library Central Search were searched for recently published articles up to December 2017. The following keywords were used; "partial adrenalectomy", "adrenal sparing", "partial nephrectomy", "nephron sparing", "kidney/renal cancer".

RESULTS

Partial adrenalectomy became an attractive alternative to total adrenalectomy avoiding adrenal insufficiency. Both minimally invasive surgery and ablative techniques were increasingly reported for adrenal OSS with adequate residual adrenal function and excellent oncological outcome. Radical nephrectomy remained for many years as the gold standard of treatment for organ-confined renal cell carcinoma. As the need to reduce the impact on renal function, more conservative approaches were utilized. Soon, the non-inferiority of nephron-sparing surgery to that of radical excision became evident and elective partial nephrectomy was gaining ground as the standard of care for small renal masses in patients with normal contralateral kidneys.

CONCLUSIONS

Herein, we present a comprehensive review of the current status of OSS in renal and adrenal tumors.

Oncologic outcomes of nephron-sparing surgery in patients with T1 multifocal renal cell carcinoma

OBJECTIVE

This study is performed to explore the pathological characteristics and oncologic outcomes of T1 multifocal renal cell carcinoma (RCC).

METHODS

The clinical data of 600 patients (442 males and 158 females) between the age of 29 and 73 years, diagnosed with T1 RCC were collected from three hospitals in China, out of which 421 cases had undergone nephron-sparing surgery (NSS) and 179 cases had undergone radical nephrectomy (RN) between December 2010 and January 2015.

RESULTS

Tumor was identified with multifocality in 32 patients (5.33%), out of which 21 were set to receive NSS, and 11 to receive RN, respectively; 21 cases of clear cell tumor, 8 cases of papillary tumor, 1 case of chromophobe tumor and 2 cases of Xp.11.2 translocation RCC. Among 568 cases of monofocal tumors, 400 patients underwent NSS, and the remaining 168 patients underwent RN, respectively. After a median follow-up of 5 years, 13 patients were found with recurrent tumors out of those who had undergone NSS, 11 with monofocal tumors and 2 with multifocal tumors containing satellite tumor nodules (p = 0.13). Out of the 32 individuals with multifocal RCC, 4 cases were reported to have died of cancer, 2 of NSS and 2 of RN. From these findings, the cancer-specific survival for NSS and RN was estimated to be 90.48% and 81.82%, respectively (p = 0.48).

CONCLUSION

The findings from the study suggested that there were pathological differences in multifocal renal tumors, and that papillary carcinoma may be more common than clear cell carcinoma. The recurrence rate and survival rate of multifocal RCC were similar to monofocal tumors. Tumor recurrence may be related to satellite tumor nodules, which can only be detected once surgery is performed.

Trifecta Outcomes in Multifocal Tumors: A Comparison Between Robotic and Open Partial Nephrectomy

OBJECTIVES

To report a comparative analysis of outcomes in patients who underwent multiple excisions for unilateral synchronous multifocal renal tumors using both open and robotic approaches.

METHODS

We retrospectively reviewed 110 patients who underwent robotic and open partial nephrectomy and had multiple tumor excisions in an ipsilateral kidney. "Trifecta" was defined as negative surgical margins, no urologic complications, and a glomerular filtration rate (GFR) preservation of ≥90% at last follow-up. Inverse probability of treatment weighting (IPTW) was applied to equilibrate treatment groups, minimize selection bias, and optimize inference on the basis of each patient's clinicodemographic characteristics.

RESULTS

Sixty-eight robotic and 42 open patient approaches had sufficient data for IPTW. After weighting, there were no statistical differences in baseline characteristics between the two groups. On adjusted analyses, robotic partial nephrectomy achieved equivalent rates of trifecta to open surgery (16.3% vs 16.5%, p = 0.99), which persisted on subgroup analyses of patients with two (20.1% vs 23.7%, p = 0.82) or more than two tumors (6.8% vs 7.4%, p = 0.95). There were no differences between robotic and open cohorts for negative margin rates, absence of complications, or GFR ≥90%. The robotic cohort had a shorter mean length of stay (3.4 vs 4.9 days, p < 0.001).

CONCLUSIONS

Surgical resection remains the mainstay for patients with unilateral, synchronous, and multifocal renal tumors. Our analysis found that both open and robotic approaches to partial nephrectomy are equally likely to achieve the "trifecta" outcome in an equilibrated high-risk group of patients. The robotic approach for these complex patients may be safe and feasible for a carefully selected group of patients.

Multiplex Partial Nephrectomy, Repeat Partial Nephrectomy, and Salvage Partial Nephrectomy Remain the Primary Treatment in Multifocal and Hereditary Kidney Cancer

The standard of care treatment for solitary renal cell carcinoma (RCC) tumors 4 cm or less is partial nephrectomy (PNx). However, multifocal kidney cancer presents unique challenges for treating physicians. Historically, total nephrectomy and hemodialysis with possible renal transplant later was the primary therapeutic strategy for these patients. Later, as nephron sparing surgical approaches improved, PNx became the standard of care for patients presenting with multifocal and hereditary RCC. Surgeries to remove multiple renal tumors simultaneously produce different perioperative outcomes and increased risk of complications. Due to these differences in technique and outcomes, the term multiplex partial nephrectomy (MxPNx) has been coined to designate these differences. Here, we discuss the role that MxPNx continues to play in multifocal RCC.

Laparoscopic Partial Nephrectomy With Sequential Precise Tumor-specific Segmental Renal Artery Clamping for Multiple Ipsilateral Renal Tumors: A New Treatment Approach and Initial Experience

OBJECTIVE

To present our surgical approach and initial experience of laparoscopic partial nephrectomy (LPN) with sequential precise tumor-specific segmental renal artery clamping in patients with multiple ipsilateral renal tumors.

MATERIALS AND METHODS

Six patients with multiple ipsilateral renal tumors having imperative indications for nephron-sparing surgery underwent LPN with sequential precise tumor-specific segmental renal artery clamping from May 2012 to September 2015. Patient demographics, perioperative variables, renal functions, and postoperative outcomes were reviewed.

RESULTS

Overall 15 tumors in 6 patients underwent the sequential precise tumor-specific segmental renal artery clamping LPN without conversion to conventional main renal artery clamping, open surgery, or radical nephrectomy. No severe complication occurred. Mean size of the tumors was 2.5 cm (range 1.8-3.5). Mean tumor-related warm ischemia time was 17 min (range 13-22). The affected kidney functions minimally decreased at recent follow-up and restored 3 months later. No positive tumor margin or extrarenal invasion breakthrough renal capsule was observed after pathologic analysis. Over 12 months' follow-up, no local recurrence and distant metastasis were discovered in these cases postoperatively.

CONCLUSION

LPN with sequential precise tumor-specific segmental renal artery clamping is a feasible approach for multiple ipsilateral renal tumors. It minimizes intraoperative warm ischemic injury and promotes encouraging postoperative function of the affected kidney.

Hereditary Kidney Cancer Syndromes and Surgical Management of the Small Renal Mass

The management of patients with hereditary kidney cancers presents unique challenges to clinicians. In addition to an earlier age of onset compared with patients with sporadic kidney cancer, those with hereditary kidney cancer syndromes often present with bilateral and/or multifocal renal tumors and are at risk for multiple de novo lesions. This population of patients may also present with extrarenal manifestations, which adds an additional layer of complexity. Physicians who manage these patients should be familiar with the underlying clinical characteristics of each hereditary kidney cancer syndrome and the suggested surgical approaches and recommendations of genetic testing for at-risk individuals.

Repeat Robotic Partial Nephrectomy: Characteristics, Complications, and Renal Functional Outcomes

INTRODUCTION

Multifocal and hereditary kidney cancers often require repeated ipsilateral nephron sparing procedures with higher blood loss and complication rates compared to first time renal surgery. Consequently, many surgeons avoid minimally invasive techniques in the setting. We present the characteristics, complications, and short-term renal functional outcomes of patients who underwent a repeat robotic partial nephrectomy (rRPNx).

MATERIALS AND METHODS

A database was retrospectively reviewed to identify patients who underwent robotic partial nephrectomies between January 2007 and December 2013. Selection criteria for the rRPNx cohort included patients who had undergone at least two ipsilateral renal surgeries, with the second procedure being an rRPNx. All other patients comprised the initial robotic partial nephrectomy (iRPNx) group.

RESULTS

One hundred twenty-four patients who underwent robotic partial nephrectomy during the study period were identified. rRPNx constituted 26 (21%) of the total cases. Age of the rRPNx cohort was similar (p = 0.56), but number of tumors resected was two-fold greater in the rRPNx group (p = 0.44). Neither surgery time nor renal clamp time was significantly longer in either group (p = 0.18 and p = 0.65, respectively). Importantly, estimated blood loss (EBL) was significantly larger than in the iRPNx group (p = 0.01). Both groups had similar intravenous pain medication administration durations (p = 0.32), but postsurgical length of stay was greater for the rRPNx patients (p = 0.011). There were no significant differences in clavian complication rates (p = 0.17-0.39), with the exception of urine leak which occurred more frequently in the rRPNx group (p = 0.01). There was no difference in percent change in serum creatinine or estimated glomerular filtration rate (p = 0.89 and p = 0.67, respectively).

CONCLUSIONS

rRPNx is safe and feasible in select patients. EBL, postoperative lengths of stay, and urine leak were the only factors significantly associated with rRPNx compared to iRPNx. Patient 3-month follow-up revealed excellent and comparable outcomes between the two groups.